A nurse is caring for a client who has a hemoglobin of 10.8 g/dL and a hematocrit of 30%. The nurse should expect the client is at risk for which of the following conditions?
Cellular hypoxia
Fluid retention
Prolonged bleeding
Impaired immunity
The Correct Answer is A
Choice A rationale:
Cellular hypoxia occurs when cells do not receive enough oxygen to meet their metabolic demands. Hemoglobin is the protein in red blood cells that carries oxygen from the lungs to the tissues. A hemoglobin level of 10.8 g/dL is below the normal range for adults (14-18 g/dL), indicating that the client has anemia. Anemia reduces the oxygen-carrying capacity of the blood, which can lead to cellular hypoxia.
Here is a detailed explanation of how anemia can lead to cellular hypoxia:
Decreased oxygen-carrying capacity: Anemia results in fewer red blood cells or reduced hemoglobin levels within those cells. As a consequence, the blood's ability to transport oxygen to the tissues is diminished.
Impaired oxygen delivery: Oxygen is transported to the tissues through the bloodstream, attached to hemoglobin within red blood cells. With fewer red blood cells or reduced hemoglobin, the delivery of oxygen to the tissues is compromised.
Decreased oxygen availability at the cellular level: As oxygen delivery is impaired, less oxygen is available to the cells for metabolic processes. This insufficient oxygen supply leads to cellular hypoxia.
Impaired cellular function: Cells require oxygen to produce energy through a process called aerobic respiration. Cellular hypoxia disrupts this process, leading to impaired cellular function.
Tissue and organ dysfunction: When a significant number of cells within a tissue or organ experience hypoxia, the function of that tissue or organ can be compromised. This can manifest in various symptoms and complications, depending on the affected organs.
Common signs and symptoms of cellular hypoxia:
Fatigue Weakness
Shortness of breath Pale skin
Dizziness Headache Chest pain
Tachycardia (rapid heart rate) Cognitive impairment
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choiceD.
Choice A rationale:
Assisting the client back into bed is not the initial action.Moving the client without assessing their condition could potentially cause harm.
Choice B rationale:
Notifying the client’s provider is important, but it should be done after assessing the client’s condition to provide accurate information.
Choice C rationale:
Informing the client’s family member is not the immediate priority.The nurse should first ensure the client’s safety and assess their condition.
Choice D rationale:
Obtaining the client’s vital signs is the initial action.This helps assess the client’s current condition and determine if there are any immediate medical needs.
Correct Answer is C
Explanation
Choice A rationale:
Bilateral flank pain is not a typical sign of an allergic blood transfusion reaction. It can be associated with other conditions, such as kidney problems, musculoskeletal issues, or abdominal aortic aneurysm. While it's important to assess flank pain, it doesn't directly suggest an allergic reaction to the transfusion.
Choice B Rationale:
Distended jugular veins can indicate fluid overload, which could potentially occur during a transfusion. However, it's not a specific sign of an allergic reaction. Fluid overload can result from various causes, including heart failure, kidney problems, or excessive fluid intake. It's crucial to monitor for fluid overload during transfusions, but it doesn't definitively point to an allergic reaction.
Choice C Rationale:
Generalized urticaria, or hives, is a hallmark sign of an allergic reaction. It's characterized by raised, red, itchy welts that can appear on various parts of the body. Hives can develop rapidly and spread extensively. During a blood transfusion, generalized urticaria strongly suggests that the patient's immune system is reacting to a component of the transfused blood, such as proteins or antibodies.
Choice D Rationale:
Blood pressure 184/92 mm Hg is elevated and could be concerning, but it's not specific to allergic reactions. High blood pressure can have various causes, including stress, pain, anxiety, or underlying hypertension. While monitoring blood pressure during transfusions is essential, it doesn't directly indicate an allergic reaction.
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